Role of Ayurveda in the conservative management of avascular necrosis of the femoral head: A case study

Abstract

Avascular necrosis (AVN) of the femoral head is the most common type of necrosis affecting the bones. Management of AVN aims at the preservation of structure, function and relief of from pain. Many surgical procedures such as drilling and insertion of bone grafts, modified Whitman or Colonna reconstruction and insertion of prosthesis are carried out to remedy the condition but all these procedures are costly with the prognosis being poor. Signs and symptoms of Avascular necrosis are nearer to asthivāha srotoduṣṭi vikāra (disorders of musculoskeletal origin) and can be considered with gambhīra avasthā (chronic stage). An effort has been made in the present study to evaluate the efficiency of Ayurvedic formulations in the conservative management of AVN of the femoral head. A case of AVN with bilateral femoral head was treated with rūkṣaṇa (Drying therapy) followed by śodhana (bio purification) and bṛhmaṇa (rejuvenation). Patient was observed for complications during whole course of treatment, untoward complications were not seen. Patient was observed for symptomatic improvements based on assessment done by the questionnaire over graded signs and symptoms before and after treatment. The results were encouraging. The therapy provided marked relief from pain, tenderness, stiffness and improvement in the gait. Conservative management of AVN through Ayurvedic principles provides significant relief and improves quality of life.

INTRODUCTION

Avascular necrosis (AVN), is osteonecrosis (dead bone) and is also called Osteochondritis Dissecans/Chandler's Disease in young adults with 60% of the cases being bilateral. This condition is one of the most challenging problems faced by orthopedic surgeons. The objectives of the treatment include the preservation of structure, function and relief from pain.[1] Many surgical procedures such as drilling, insertion of bone grafts, modified Whitman or Colonna reconstruction and insertion of prosthesis are carried out to remedy this condition.

CASE REPORT

A 37 years old male mechanical engineer reported to the Out Patient Department of Pañcakarma, SDM College of Ayurveda and Hospital, Hassan, Karnataka, India with complaints of pain and stiffness in bilateral anterior hip to knee region since one year which was associated with difficulty in doing normal daily activities such as walking, taking bath etc., Aggravating factors were cold weather, gastric upset and supine posture. Alleviating factors were warm food and warm weather. The patient claimed to be apparently healthy one year earlier with the pain and stiffness developing gradually. The pain was constant throughout the day and aggravated during the night hours. He consulted a doctor at his native place Kolkata for relief from these symptoms. He was referred to the department of Neurology of a popular hospital and advised pain killers, which did not relieve the symptoms. Thereafter, the doctor at the Orthopedics department diagnosed his problem as Avascular Necrosis of Bilateral neck of Femur with the aid of MRI. Then as per advice of Orthopedic Surgeon he underwent decompression of left femur. After a period of one month, the patient started developing the symptoms that were present before the surgical intervention. The Orthopedic surgeon recommended one more surgical intervention but the patient was reluctant, and he approached our hospital for conservative and better treatment. The condition of the patient during first visit was pain, stiffness and heaviness in both the lower limbs, and disability to perform regular activities.

On examination patient presented with

• Third degree tenderness over bilateral thigh, patient was not be able lift the left limb even up to 10 degrees

• Gait - Trendelenberg Sign was positive.

Movements

• Pain on movement of the limb such as flexion, extension, lateral flexion and rotation.

Motor system

• Crepitus – absent

• Attitude of the limbs – flexed upper and lower limbs

• Nutrition – moderate

• Tone – hypotonic in left lower limb

• Power – right side – normal power and in left lower limb – Grade 4

• Involuntary movement – absent.

Considering the history and examination of the patient, treatment was planned with a cikitsā krama (treatment plan) based on principles of ṣaḍvidhopakarma (six principles of treatment). Presentation of the patient with pain and stiffness in bilateral anterior hip to knee region showed the involvement of vātakapha duṣṭi associated with the Asthivāha srotas (disorders of musculoskeletal origin) and hence rūkṣaṇa with agnicikitsā lepa, Pariṣeka (a type of sudation) with Dhānyāmla, Daśamūla Kaṣāya and internal administration of Hiṅgvaṣṭaka vaṭi two tablets thrice daily before food. Followed by śodhana (Bio purification) in the form of Mañjiṣṭhādi kṣāra basti (therapeutic enema) Table 1 in modified yoga basti schedule was administered. Sarvāṅga cūrṇa bāṣpa svedana (sudation) [Table 2] with Dhānyāmla bāṣpa and Amṛtottara Kaṣāya 20 ml thrice daily was given.

Table 1.

Ingredients of Mañjiṣṭhādi Kṣāra Basti

Table 2.

Ingredients of Cūrṇa piṇḍa sveda

Bṛhmaṇa was done with Ṣaṣṭika śāli piṇḍa svedana (sudation using medicated rice), Mañjiṣṭhādi Kṣīra basti (enema) Table 3 with modified kāla basti schedule for 7 days.

Table 3.

Ingredients of Mañjiṣṭhādi Kṣīra Basti

Pathya was advised with nidāna parivarjana (avoiding all aggravating habits) and during the course of treatment patient was given low carbohydrate diet. Patient was observed for complications during whole course of treatment and no untoward complication was observed. During the course of rūkṣaṇa patient did not find significant relief but slight improvement was present during the course of śodhana therapy and in that, the patient was able to lift lower limb to 30 degrees due to stiffness still present. After the course of the bṛhmaṇa therapy and kṣīra basti on day 12, the patient was able to lift the limb upto 70 degrees with complete reduction of stiffness Table 4. Overall, the patient felt symptomatic improvements. On discharge, patient was advised Guggulu tikta Kaṣāya (decoction) 15 ml TID with 30 ml of hot water before food.

Table 4.

Comparison of symptoms

CONCLUSION

Patient of AVN with the bilateral femoral head was treated with rūkṣaṇa followed by śodhana and bṛhmaṇa line of treatment. In asthigatavāta tikta rasa auṣadhi (medicines with bitter taste) are beneficial.[2]Ācāryas while explaining the dhātupāka avasthā (metabolism process) clearly detail the importance of agni which is singularly responsible for the formation of the dhātus. Thus, correction of agni should be done by administration of dīpana and pācana dravyas and the process of dhātu pāka must be strengthened,[3] the doṣas must be balanced and metabolic toxins must be eliminated from the dhātus through pañcakarma. As the pre-operative process, ācāryas have prescribed “bṛhmyāṃstu mṛdu langhayet”[4] which means the usage of rūkṣaṇa for better bṛhmaṇa (rejuvenation). Hence the treatment modalities such as udvartana[5] (powder massage) were planned in order to remove srotorodha (obstructions) and sthirī karaṇa of aṅgas[6] (imparting compactness to body). These modalities of therapy are responsible for removal of vitiated medas whereas pācana medicines are also explained as a variety of rūkṣaṇa. Thus rūkṣaṇa cikitsā[7] is beneficial. Hence, initially pariṣeka with Dhānyāmla and Daśamūla kaṣāya was planned. Basti is one among the pañcakarmas which clearly shows its efficacy[8] in chronic conditions due to its therapeutic effect especially in its bṛhmaṇa action (rejuvenating enema). Therefore in AVN like conditions this can prove to be a better modality of treatment, as AVN represents gambhīra asthi dhātu involvement. Hence the use of māṃsa rasa basti and yāpana basti which contains Madanaphala (Randia dumetorum) in kāla and karma basti format may be given. However Anuvāsana (oil enema) can be administered with the use of a tikta ghṛta[9] such as Ashvagandhā ghṛta,[10] these medicaments may also administered in the form of śodhāṅga snehapāna if initial śodhāṅga karma in the form of virechana is planned before basti.[11] Such a basti regimen can rejuvenate and further help in alleviating dhātukṣaya which is caused due to the vāta doṣa and may aid in neovascularization.[12] The therapy provided marked relief from pain, tenderness, Stiffness and improvement in the gait. The results were encouraging. The grade of AVN did not worsen and was maintained as seen during the follow up. The therapy is cost effective. Conservative management of AVN through Ayurvedic principles provides significant relief and improves quality of life.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.